โดย พญ. กนิษฐา โชคสวัสดิ์ Acute Pancreatitis โดย พญ. กนิษฐา โชคสวัสดิ์

Pancreatitis Inflammation of the pancreatic parenchyma Acute or Chronic • Acute pancreatitis = A transient inflammation that resolves with or without complications • Chronic pancreatitis = Continuous inflammation resulting in progressive anatomic and functional damage to the pancreas

Acute Pancreatitis • Gallstones (45%) Etiology • Alcohol abuse (35%) • Others (10%) • Idiopathic (10%) ** Males (alcohol) > Females (choledocholithiasis)

Acute Pancreatitis Pathophysiology • Activation of digestive zymogens inside acinar cells  Acinar cell injury  inflammatory cell recruitment + activation, generation + release of cytokines & other mediators

Acute Pancreatitis Clinical Presentation Mid epigastric abdominal pain Steady, boring pain Radiation to the left upper back Anorexia, nausea ± vomiting ± diarrhea Low grade fever Inflammation or secondary infection Presentations associated with complications Shock Multi-system failure

Acute Pancreatitis Exam Findings • Abdominal tenderness • Fever (76%) • Abdominal guarding (68%) • Abdominal distension (65%) • Tachycardia (65%) • Hypoactive bowel sounds • Jaundice (28%) • Dyspnea (10%) • Hemodynamic changes (10%) • Melena or hematemesis (5%) • Cullen’s sign • Grey-Turner sign • Left pleural effusion

Acute Pancreatitis Cullen’s sign Grey-Turner sign

Investigation

Diagnosis: Biochemical Serum Amylase elevated Nonspecific Returns to normal in 48-72 hours Normal amylase does not exclude pancreatitis Level of elevation does not predict disease severity Serum Lipase elevated Specific for pancreatic disease Returns to normal in 7-14 days Serum Electrolytes Hypocalcemia (25%) Hyperglycemia Complete Blood Count (CBC) White Blood Cells increased to 15k-20k Lipids Elevated Hypertriglyceridemia Liver Function Tests Serum Bilirubin elevated ALT elevated AST Hypoalbuminemia (Poor prognosis) Lactate Dehydrogenase (LDH) elevated (Poor prognosis)

Diagnosis Ultrasound - Most useful initial test for gallstone etiology Dynamic contrast-enhanced CT (CECT) - the imaging modality of choice for diagnosis, staging, and detection of complications of acute pancreatitis.

Severity assessment

APACHE II SCORE

Ranson's criteria On admission Within 48 hours Age > 55 yrs WCC > 16,000 LDH > 600 U/l AST >120 U/l Glucose > 10 mmol/l Within 48 hours Haematocrit fall >10% Urea rise >0.9 mmol/l Calcium < 2 mmol pO2 < 60 mmHg Base deficit > 4 Fluid sequestration > 6L

Ranson criteria - prognosis Mortality correlates with number of criteria 0-2 1% 3-4 15% 5-6 40% 7-8 100%

CT Severity index serial CT scans are important for following the progression of the disease and for detecting additional complications. In Balthazar’s series

Complication

Acute Pancreatitis Mild Severe Overall mortality 10 -15% - severe disease as high as 30%

Severe Acute Pancreatitis - Definition 1. Organ failure • Shock, pulmonary insufficiency, renal failure, GI bleeding 2. Local complications • Pseudocyst, abscess, pancreatic necrosis 3. >= 3 Ranson criteria Overall mortality 30% , Early (MOFS), late (infection)

Local Complications • Peri-pancreatic fluid collections • 57% of patients • Initially ill-defined • Usually managed conservatively • Pseudocysts • Pancreatic necrosis

Acute pseudocyst

Pancreatic necrosis

Peripancreatic and retroperitoneal edema

Treatment

Treatment of acute pancreatitis Supportive  Eliminating of oral intake Intravenous hydration Parenteral analgesia NG suction : ileus or severe vomiting Collection of electrolyte and glucose abnormalities vascular, respiratory and renal support Removal of factors : drug or alcohol

Surgical Kelly and Wagner Pt who underwent surgery earlier(<48hrs) had higher mortality and morbidity rates than those who underwent surgery later(>48hrs) This finding was even more pronounced in those with severe pancreatitis

Surgical Stone et al. No deference in mortality between Pt randomly assigned to early biliary surgery (<72hr) and those assigned to late surgery(3mo after admission)

Surgery The traditional indication for surgery  acute abdomen removal of impact stone from the CBD(emergency or elective) Drainage of pancreatic fluid collections Debridement of necrotic tissue

Antibiotics Three early controlled trials Ampicillin did not change the course of mild acute alcoholic pancreatitis Imipenem reduced the incidence of pancreatitis sepsis in pt with necrotizing pancreatitis

Inhibiting pancreatic secretion Cimetidine Atropine Calcitonin Glucagon Somatostatin Fluororacil  not been shown to change the course of the disease

Summary No specific treatment for acute pancreatitis Supportive therapy Vigorous intravenous hydration Parenteral analgesia Collection of electrolyte and glucose abnormalities and vascular, respiratory and renal support

Summary The use of antiproteases and inhibitor of pancreatic secretion cannot be recommended Immediate endoscopic removal of impacted stones in pt with severe disease appears to reduce morbidity

Summary Controlled studies are needed to demonstrate whether debridement of sterile necrotic tissue improve outcome Infected necrotic tissue and infected collections of fluid are best treated by surgical debridement